Provider Demographics
NPI:1063101277
Name:FANT, REBECCA ELIZABETH (NP)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:ELIZABETH
Last Name:FANT
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3078 S CUSTER RD
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:MI
Mailing Address - Zip Code:48161-9772
Mailing Address - Country:US
Mailing Address - Phone:313-287-8845
Mailing Address - Fax:
Practice Address - Street 1:951 HICKORY CREEK DR
Practice Address - Street 2:
Practice Address - City:TEMPERANCE
Practice Address - State:MI
Practice Address - Zip Code:48182-2327
Practice Address - Country:US
Practice Address - Phone:734-206-8200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-03
Last Update Date:2024-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704274218363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily